<form method="get" class="form-horizontal" id="baseMessageForm">
    <script id="baseMessageComp" type="plain/text">
    <div>
        <div class="row base-message-input">
            <div class="col-xs-3 input_div">
                <span class="input-title"><i class="mandatory"></i>患者姓名</span>
                <input type="text" placeholder="请输入患者姓名" class="form-control but_Fonts" name="name" model='baseMess.name'
                       id='name' maxLength="16">
            </div>
            <div class="col-xs-3 input_div">
                <span class="input-title"><i class="mandatory"></i>手机号码</span>
                <input type="number" maxlength='11' placeholder="请输入手机号码" class="form-control phoneLength but_Fonts" name="phone"
                       model='baseMess.phone' id='phone'>

            </div>
            <div class="col-xs-3 input_div">
                <span class="input-title"><i class="mandatory"></i>医院</span>
                <select class="form-control m-b margin-bottom-0 but_Fonts hospitalIdF" id="hospitalId" name="hospital_id" disabled="disabled"
                        model='baseMess.hospital_id' on-change="hospitalChange()">
                    @if($hospitals instanceof \Illuminate\Database\Eloquent\Collection)
            @foreach($hospitals as $hospital)
                <option value="{{ $hospital->id }}">{{ $hospital->name }}</option>
                        @endforeach
        @else
            <option value="{{ $hospitals->id }}">{{ $hospitals->name }}</option>
                    @endif
        </select>
    </div>
    <div class="col-xs-3 input_div">
        <span class="input-title">医生</span>
        <select class="form-control m-b margin-bottom-0 but_Fonts" id="doctorId" name="doctor_id"
                model='baseMess.doctor_id'>
@if($doctors instanceof \Illuminate\Database\Eloquent\Collection)
            @if ($doctors->count() == 0)
                <option value=""></option>
@endif
            @foreach($doctors as $doctor)
                <option value="{{ $doctor->id }}" @if($selectid==$doctor->id)  selected @endif>{{ $doctor->name }}</option>
                        @endforeach
        @else
            <option value="{{ $doctors->id }}" @if($selectid==$doctors->id)  selected @endif >{{ $doctors->name }}</option>
                    @endif
        </select>
    </div>
    <div class="col-xs-3 margin-top-15 input_div">
        <span class="input-title"><i class="mandatory"></i>性别</span>
        <select class="form-control m-b margin-bottom-0 but_Fonts but_Fonts" name="sex" model='baseMess.sex' id="sexSelect">
            <option value='1'>女</option>
            <option value='0'>男</option>
        </select>
    </div>
    <div class="col-xs-3 margin-top-15 input_div">
        <span class="input-title"><i class="mandatory"></i>出生日期</span>
        <input type="text" class="form-control birthday but_Fonts" id="birthday" data-toggle="datepicker"
               placeholder="请输入出生日期" name="birthday" model='baseMess.birthday'>
    </div>
    <div class="col-xs-3 margin-top-15 input_div">
        <span class="input-title">病案号</span>
        <input type="text" maxLength="20" placeholder="请输入病案号" class="form-control but_Fonts" name="medical_number"
               model='baseMess.medical_number' id='medical_number'>
    </div>
    <div class="col-xs-3 margin-top-15 input_div">
        <span class="input-title">就诊日期</span>
        <input type="text" class="form-control datepicker but_Fonts" id="clinicAt" data-toggle="datepicker"
               placeholder="请输入就诊日期" name="clinic_at" model='baseMess.clinic_at'>
    </div>
    <div class="col-xs-3 margin-top-15 input_div">
        <span class="input-title">身份证号</span>
        <input type="text" class="form-control but_Fonts" maxLength="18" id="cardnumber" placeholder="请输入身份证号"
               name="cardnumber" model='baseMess.cardnumber'>
    </div>
    <div class="col-xs-3 margin-top-15 input_div">
        <span class="input-title">糖尿病类型</span>
        <select class="form-control m-b margin-bottom-0 but_Fonts" name="diabetes_type" model='baseMess.diabetes_type'
                id='diabetes_type'>
            <option value=''>请选择</option>
            <option value='1'>1型</option>
            <option value='2'>2型</option>
            <option value='3'>其他</option>
{{--<option value='4'>特殊</option>--}}
        {{--<option value='5'>待查</option>--}}
        </select>
    </div>
{{--<div class="col-xs-3 margin-top-15">--}}
        {{--<span class="input-title">是否妊娠期</span>--}}
        {{--<select class="form-control m-b margin-bottom-0" name="is_gestation" model='baseMess.is_gestation' id='is_gestation'>--}}
        {{--<option value='0' disabled>无</option>--}}
        {{--<option value='1'>否</option>--}}
        {{--<option value='2'>是</option>--}}
        {{--</select>--}}
        {{--</div>--}}
        <div class="col-xs-3 margin-top-15 input_div">
            <span class="input-title">特病</span>
            <select class="form-control m-b margin-bottom-0 but_Fonts" name="special_illness" model='baseMess.special_illness'
                    id='special_illness'>
                <option value=''>请选择</option>
                <option value='0'>无</option>
                <option value='1'>肾透析</option>
                <option value='2'>肾移植</option>
                <option value='3'>腹膜透析</option>
                <option value='4'>癌症放化疗</option>
                <option value='5'>其他</option>
            </select>
        </div>
        <div class="col-xs-3 margin-top-15 input_div">
            <span class="input-title">民族</span>
            <select class="form-control m-b margin-bottom-0 but_Fonts" name="nation" model='baseMess.nation' id='nation'>
                <option value="1">汉族</option>
                <option value="2">蒙古族</option>
                <option value="3">回族</option>
                <option value="4">藏族</option>
                <option value="5">维吾尔族</option>
                <option value="6">苗族</option>
                <option value="7">彝族</option>
                <option value="8">壮族</option>
                <option value="9">布依族</option>
                <option value="10">朝鲜族</option>
                <option value="11">满族</option>
                <option value="12">侗族</option>
                <option value="13">瑶族</option>
                <option value="14">白族</option>
                <option value="15">土家族</option>
                <option value="16">哈尼族</option>
                <option value="17">哈萨克族</option>
                <option value="18">傣族</option>
                <option value="19">黎族</option>
                <option value="20">傈僳族</option>
                <option value="21">佤族</option>
                <option value="22">畲族</option>
                <option value="23">高山族</option>
                <option value="24">拉祜族</option>
                <option value="25">水族</option>
                <option value="26">东乡族</option>
                <option value="27">纳西族</option>
                <option value="28">景颇族</option>
                <option value="29">柯尔克孜族</option>
                <option value="30">土族</option>
                <option value="31">达斡尔族</option>
                <option value="32">仫佬族</option>
                <option value="33">羌族</option>
                <option value="34">布朗族</option>
                <option value="35">撒拉族</option>
                <option value="36">毛南族</option>
                <option value="37">仡佬族</option>
                <option value="38">锡伯族</option>
                <option value="39">阿昌族</option>
                <option value="40">普米族</option>
                <option value="41">塔吉克族</option>
                <option value="42">怒族</option>
                <option value="43">乌孜别克族</option>
                <option value="44">俄罗斯族</option>
                <option value="45">鄂温克族</option>
                <option value="46">德昂族</option>
                <option value="47">保安族</option>
                <option value="48">裕固族</option>
                <option value="49">京族</option>
                <option value="50">塔塔尔族</option>
                <option value="51">独龙族</option>
                <option value="52">鄂伦春族</option>
                <option value="53">赫哲族</option>
                <option value="54">门巴族</option>
                <option value="55">珞巴族</option>
                <option value="56">基诺族</option>
            </select>
        </div>
        <div class="col-xs-12">
            <div id="distpicker" class="row">
                <div class="col-xs-3 margin-top-15 input_div">
                    <span class="input-title">省份</span>
                    <select class="form-control but_Fonts" id="province" name="province" model='baseMess.province'
                            on-change="provinceChange()">
                        <option value="0">请选择</option>
@foreach($address['provinces'] as $province)
            <option value="{{ $province->id }}">{{ $province->name }}</option>
                            @endforeach
        </select>
    </div>
    <div class="col-xs-3 margin-top-15 input_div">
        <span class="input-title">城市</span>
        <select class="form-control but_Fonts" id="city" name="city" model='baseMess.city'
                on-change="cityChange()">
            <option value="">请选择</option>
        </select>
    </div>
    <div class="col-xs-3 margin-top-15 input_div">
        <span class="input-title">区县</span>
        <select class="form-control but_Fonts" id="county" name="county" model='baseMess.county'>
            <option value="">请选择</option>
        </select>
    </div>
@if(!$scene->isWestern())
            <div class="col-xs-3 margin-top-15 input_div">
                <span class="input-title"><i class="mandatory"></i>糖尿病阶段</span>
                <select class="form-control but_Fonts" id="diabetes_stage" name="diabetes_stage">
                    <option value="">请选择</option>
@foreach(\App\Models\Patient::$diabetes_stage_types as $key => $value)
                @if($key == request()->query('stage'))
                    <option value="{{ $key }}" selected>{{ $value }}</option>
                                @else
                    <option value="{{ $key }}">{{ $value }}</option>
                                @endif
            @endforeach
            </select>
        </div>
@endif
        </div>
    </div>
</div>
<div class="row">
    <div class="col-xs-12 text-right margin-top-15">
        <button type="button" class="btn btn-primary btn-lg" on-click="saveMessage()" lazy='3000'>保存</button>
    </div>
</div>
</div>



    </script>
</form>